Provider Demographics
NPI:1497783963
Name:HAFNER-FOGARTY, REBECCA J (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:HAFNER-FOGARTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33491 135TH AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MN
Mailing Address - Zip Code:56310-9617
Mailing Address - Country:US
Mailing Address - Phone:320-356-1019
Mailing Address - Fax:
Practice Address - Street 1:33491 135TH AVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:MN
Practice Address - Zip Code:56310-9617
Practice Address - Country:US
Practice Address - Phone:320-356-1019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND80201Medicare UPIN